Health Policy and Health Services Research
Background: The number of prescribed opioid tablets in US emergency departments (EDs) greatly varies despite recommendations for a 3-day or less supply. Setting Electronic medical record (EMR) default amounts lower than the baseline average (e.g. 10 tablets) reduces the tablet number prescribed, potential opioid use and misuse. Conversely if set too high, prescribers are nudged into prescribing more than they would have without a default. It is unknown whether EMRs utilized in EDs have opioid defaults and if they comply with recommendations (e.g. ≤12 tablets). We conducted a national survey of US EDs to determine the prevalence and size of defaults deployed in opioid discharge prescriptions.
Methods: We surveyed the ACEP Emergency Medicine Practice Research Network in May 2017. Outcomes included 1) whether defaults existed for hydrocodone/acetaminophen (5-325 mg) and oxycodone/acetaminophen (5-325mg), 2) whether default quantities existed for each, and 3) whether quantities were ≤12 tablets. We collected the ZIP code of respondents’ ED mapped to US state and whether a law was enacted limiting opioid prescription amounts using data from the National Conference of State Legislatures. Differences between tablet numbers, guidelines and regional/state laws were tested using chi-square tests.
Results: Defaults were present in 161 (54%) EDs. The median default for both hydrocodone and oxycodone was 15 tablets (IQR 12-20) with 22.3% and 25.0% being for ≤12, respectively. Of EDs with defaults, 15 (10%) reported defaults 30 tabs (range 30-90 tablets). Northeast region EDs had the largest proportion of defaults for ≤12 tablets (38.6%) versus no default (43.9%) or > 12 tablets (17.5%, p=0.014). EDs with defaults < 12 tablets were more likely in states with prescribing limits (50%) compared to those with no defaults (30%) or default > 12 tablets (36%) (p = 0.023). Of the 893 members surveyed, 299 (33%) from 47 states responded.
Conclusion: We found significant variation (from 1-90 tablets) with 42% having defaults >12 tablets among those with defaults. A significant proportion of existing EMR defaults may encourage relatively higher prescribing quantities. Guideline concordant EMR defaults were more common in states with opioid prescribing limits. There appears to be significant opportunities to change ED EMR opioid defaults to be concordant with existing national and state guidelines.